Objective Our objective was to analyze factors predicting outcomes after a total pancreatectomy and islet autotransplantation (TP-IAT). Background Chronic pancreatitis (CP) is increasingly treated by a TP-IAT. Postoperative outcomes are generally favorable, but a minority of patients fare poorly. Methods In our single-centered study, we analyzed the records of 581 patients with CP who underwent a TP-IAT. Endpoints included persistent postoperative “pancreatic pain” similar to preoperative levels, narcotic use for any reason, and islet graft failure at 1 year. Results In our patients, the duration (mean ± SD) of CP before their TP-IAT was 7.1 ±0.3 years and narcotic usage of 3.3 ± 0.2 years. Pediatric patients had better postoperative outcomes. Among adult patients, the odds of narcotic use at 1 year were increased by previous endoscopic retrograde cholangiopancreatography (ERCP) and stent placement, and a high number of previous stents (>3). Independent risk factors for pancreatic pain at 1 year were pancreas divisum, previous body mass index >30, and a high number of previous stents (>3). The strongest independent risk factor for islet graft failure was a low islet yield—in islet equivalents (IEQ)—per kilogram of body weight. We noted a strong dose-response relationship between the lowest-yield category (<2000 IEQ) and the highest (≥5000 IEQ or more). Islet graft failure was 25-fold more likely in the lowest-yield category. Conclusions This article represents the largest study of factors predicting outcomes after a TP-IAT. Preoperatively, the patient subgroups we identified warrant further attention.

Objective Describe the surgical technique, complications and long term outcomes of total pancreatectomy and islet auto transplantation (TP-IAT) in a large series of pediatric patients. Summary Background Data Surgical management of childhood pancreatitis is not clear; partial resection or drainage procedures often provide transient pain relief, but long term recurrence is common due to the diffuse involvement of the pancreas. Total pancreatectomy (TP) removes the source of the pain, while islet auto transplantation (IAT) potentially can prevent or minimize TP-related diabetes. Methods Retrospective review of 75 children undergoing TP-IAT for chronic pancreatitis who had failed medical, endoscopic or surgical treatment between 1989–2012. Results Pancreatitis pain and the severity of pain statistically improved in 90% of patients after TP-IAT (p =<0.001). The relief from narcotics was sustained. Of the 75 patients undergoing TP-IAT, 31 (41.3%) achieved insulin independence. Younger age (p=0.032), lack of prior Puestow (p=0.018), lower body surface area (p=0.048), IEQ per Kg Body Weight (p=0.001) and total IEQ (100,000) (0.004) were associated with insulin independence. By multivariate analysis, 3 factors were associated with insulin independence after TP-IAT:(1) male gender, (2) lower body surface area and the (3) higher total IEQ per kilogram body weight. Total IEQ (100,000) was the single factor most strongly associated with insulin independence (OR = 2.62; p value < 0.001). Conclusions TP-IAT provides sustained pain relief and improved quality of life. The β cell function is dependent on islet yield. TP-IAT is an effective therapy for children with painful pancreatitis that fail medical and or endoscopic management

Fear of diabetes and major surgery may prohibit referral of young children severely impacted by pancreatitis for total pancreatectomy and islet autotransplant (TPIAT). We evaluated outcomes in our youngest TPIAT recipients, age 3–8 years at surgery. Medical records were reviewed for 17 children (9 female) age ≤8 years undergoing TPIAT from 2000–2014. Most (14/17) had genetic risk factors for pancreatitis. Since 2006, TPIAT recipients were followed prospectively with health questionnaires including assessments of pain and narcotic use, and scheduled HbA1c and mixed meal tolerance tests (6 mL/kg Boost HP) before surgery, and at regular intervals after. Patients are 1–11 years post TPIAT (median 2.2 years). Data are reported as median (25th, 75th percentile). All had relief of pain, with all 17 patients off narcotics at most recent follow up. Hospitalization rates decreased from 5.0 hospitalization episodes per person-year of follow up before TPIAT, to 0.35 episodes per person-year of follow up after TPIAT. Fourteen (82%) discontinued insulin, higher than the observed insulin independence rate of 41% in 399 patients >8 years of age undergoing TPIAT over the same interval (p=0.004). Median post-TPIAT HbA1c was 5.9% (5.6, 6.3%), and within patient post-TPIAT mean HbA1c was ≤6.5% for all but 2 patients. Very young children with severe refractory chronic pancreatitis may be good candidates for TPIAT, with high rates of pain relief and insulin independence, and excellent glycemic control in the majority.

U.S. soldiers' appraisal and experience of the Kosovo peacekeeping mission is described. Using a prospective design, we evaluated the prevalence, severity, and predictors of several mental health outcomes at redeployment. We found that peacekeepers frequently were exposed to potentially traumatizing and other stressful events while in Kosovo, but on average, their appraisal of those events was moderate. Postdeployment psychopathology was also low--soldiers endorsed more severe mental health difficulties at predeployment, which suggests anticipatory negative affect. After controlling for the impact of predeployment stressors, we examined the contribution of potentially traumatizing events, general overseas military duty stressors, negative aspects of peacekeeping roles, and generic positive military experiences, including morale, to explain variance in four outcomes: post-traumatic stress disorder, depression, hostility and aggression problems, and problems with alcohol abuse. Findings indicate that hostility and drinking may be more chronic problems that emerge during stressful times, whereas depression and post-traumatic stress disorder symptoms may be more apt to fluctuate and are associated with potentially traumatizing experiences during peacekeeping. The implications and limitations of the study are discussed.

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Thus, Thymoglobulin induction was associated with a decreased incidence of acute rejection and an increased incidence of EBV infection in pediatric KTx recipients. EBV monitoring should be performed in EBV-naive recipients receiving Thymoglobulin.

Infants deserve earlier consideration for KTx. Length of initial hospital stay and patient and graft survival rates after KTx have improved in infants since 1984.

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